Factors influencing surgical decision-making in pediatric and adolescent scaphoid fractures

We aimed to assess the risk of conversion to surgical intervention in children initially managed with casting for an isolated scaphoid fracture with a secondary aim of assessing the incidence and management of occult scaphoid fractures without signs of fracture on initial radiographs. A retrospective review was performed. Our primary outcome was conversion to surgery. Subsequent evidence of fracture in those with only initial snuffbox tenderness was recorded for the secondary aim. Three hundred and eighty-four wrists with radiographic evidence of a scaphoid fracture were included. Twenty-one scaphoid fractures failed conservative treatment. Subjects that failed cast treatment were older than those that did not (15.9 years vs. 14.0 years; P < 0.001). Subjects with a delay in treatment of at least 6 weeks from injury were 8x more likely to require surgery than those with prompt treatment (P < 0.001). Surgical conversion varied based on fracture location: distal pole 0.7%, waist 7.4%, and proximal pole 23.5% of the time (P < 0.001). A total of 14% of wrists managed in a cast without radiographic evidence of fracture at presentation subsequently demonstrated a fracture on follow-up films. The primary predictor of failed conservative treatment is a delay in presentation. We found that the sequelae of delay in presentation or diagnosis of a scaphoid fracture increased the likelihood of requiring surgery. Therefore, clinical suspicion should dictate early management and these factors should play a role in determining when to initiate casting in the setting of pediatric scaphoid fractures. Level of evidence: III.